Submit a Provider Referral | Rise & Reflect

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Rise and Reflect Community Services LLC

NC State Regulated · NC Medicaid Provider

Referral Form

Rise & Reflect Community Services LLC  ·  (252) 572-6547  ·  Fax: (252) 303-5564  ·  info@riseandreflectnc.com

HIPAA-Covered Transmission — Authorized Providers Only

  • 🔒 This form is transmitted over TLS-encrypted HTTPS. Data in transit is encrypted end-to-end.
  • 📧 Submissions are received by a Google Workspace account covered under a signed Business Associate Agreement (BAA) with Google LLC, satisfying 45 CFR §164.308 requirements.
  • 🚫 Do not submit Social Security Numbers, full financial account numbers, or detailed substance use records. Substance use history is limited to Yes/No — detailed 42 CFR Part 2-protected information must be collected through secure, consent-driven channels.
  • 📋 Only minimum necessary information should be submitted, consistent with HIPAA's Minimum Necessary Standard (45 CFR §164.502(b)).
  • 🔑 This form is intended for use by licensed providers, care managers, hospital discharge staff, DSS workers, and other authorized referral sources only. Unauthorized use may constitute a violation of 45 CFR Part 164.

Fields marked with * are required. All information is protected under HIPAA. Submission of this form constitutes a request for services and requires signed consent.

1

Referral Source Information

Who is making this referral?

2

Individual / Client Information

Demographics required by NC DHHS and NC Medicaid

3

Guardian / Legal Representative

Complete if individual is a minor or has a legal guardian

4

Insurance / Payer Information

Required for NC Medicaid authorization and billing

Medicaid ID and Medicare ID numbers should not be submitted on this form. Please include them with supporting documentation sent via fax to (252) 303-5564 or attach to a secure follow-up communication.

5

Services Requested

Select all that apply — NC Medicaid covered services

Please select at least one service.

6

Clinical Information

Provide current diagnostic and treatment history

Minimum necessary only — 300 character limit.

Minimum necessary only — 200 character limit.

Minimum necessary only — 300 character limit.

Minimum necessary only — 200 character limit.

Detailed SUD records are protected under 42 CFR Part 2 and must be collected through secure, consent-driven channels — not this form.

7

Safety Information

Required for all referrals — NC state regulation

8

Strengths, Barriers & Additional Information

9

Consent & Authorization

HIPAA-required — must be completed to process referral

Authorization Statement

By submitting this referral, the undersigned certifies that: (1) a Release of Information (ROI) or appropriate consent has been obtained from the individual or their legal guardian as required by HIPAA and 42 CFR Part 2; (2) the information provided is accurate and complete to the best of their knowledge; and (3) they are authorized to make this referral on behalf of the individual named above.

For urgent referrals, call (252) 572-6547 directly.